2014 Evidence-Based Guideline for the Management of High Blood

Pressure in Adults

Presented by : Dr. Jeevan JacobModerator : Dr. Reema

JNC 8

Introduction Staging of Hypertension Questions guiding the Review Recommendations Limitation Conclusion

Contents

Hypertension remains one of the most important preventable contributors to disease and death.

Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes.

This report highlights the Evidence-Based Guideline for the Management of High Blood Pressure in Adults.

Introduction

Originally constituted as the “EIGHTH JOINT NATIONAL COMMITTEE

ON THE PREVENTION,DETECTION,EVALUATION,AND TREATMENT

OF HIGH BLOOD PRESSURE(JNC 8)”.

In June 2013,NHLBI announced its decision to discontinue developing

clinical guidelines including those in process,instead partnering with selected

organizations that would develop the guidelines.

Not an NHLBI sanctioned report and does not reflect the views of NHLBI.

Circulation 2013;128(15):1713-1715.

The panel members appointed to the JNC 8 used evidence-based methods, developing Evidence Statements and recommendations for blood pressure treatment.

Recommendations are based on a systematic review of the literature to meet needs of the primary care physician.

This is an Executive summary of the evidence and is provides clear recommendations for all clinicians.

Guideline focuses on the panel’s most debated questions related to high BP management.

These questions address:

◦ Thresholds and goals for treatment of hypertension.

◦ Whether particular antihypertensive drugs have a bearing health outcomes.

Questions Guiding the Evidence Review

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① In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Threshold

② In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvement in health outcome? Goal

③ In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcome? Impact of drugs

Questions Guiding the Evidence Review

Expertise in HTN (n=14),

Primary care (n=6),Geriatrics (n=2),

Cardiology (n=2),Nephrology (n=3)

Nursing =1,Pharmacology n=2,Clinical trials n =6,

EBM ,n=3

Senior scientist from NIDDK

Senior medical officer from NHLBI

PANEL MEMBERS

Review in January 2013 NHLBI 20 reviewers 16 federal agencies

Reviewed and discussed by panel MARCH TO JUNE 2013

-revised document

THE PROCESS

Recommendations

Nine recommendations are made reflecting these questions.

Recommendations 1 -5 address questions 1 & 2 concerning thresholds and goals for BP treatment.

Recommendations 6, 7, 8 address question concerning selection of antihypertensive drugs.

Recommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugs

Concerning thresholds and goals.

Recommendations 1 -5

General population aged 60 years or older

Recommendation 1

SBP ≥150 mmHg Or

DBP ≥ 90mmHg

Goal of Treatment :

SBP <150 mmHg OR

DBP of < 90mmHg.

Initiate Treatment at :

General population < 60 years

Recommendation 2

Initiate Treatment at : DBP ≥ 90mmHg

Goal of Treatment :

DBP of < 90mmHg.

General population < 60 years

Recommendation 3

SBP ≥ 140 mmHg

Goal of Treatment :

SBP of < 140 mmHg.

Initiate Treatment at :

Population aged 18 years or older with CKD

Recommendation 4

Initiate Treatment at:

SBP ≥ 140 mmHgOr

DBP ≥ 90 mmHg

Goal of Treatment :

SBP < 140 mmHgOr

DBP < 90 mmHg

Population aged 18 years or older with diabetes

Recommendation 5

Initiate Treatment at:

SBP ≥ 140 mmHgOr

DBP ≥ 90 mmHg

Goal of Treatment :

SBP < 140 mmHgOr

DBP < 90 mmHg

Concerning selection of antihypertensive drugs.

Recommendations6,7,8

In General nonblack population, including those with diabetes

Initial antihypertensive treatment should include any of the following:

A thiazide-type diuretic Calcium channel blocker (CCB) Angiotensin-converting enzyme inhibitor

(ACEI) or Angiotensin receptor blocker (ARB).

Recommendation 6

In general black population, including those with diabetes:

Initial antihypertensive treatment should include :

Thiazide-type diuretic

CCB.

Recommendation 7

Population aged 18 years or older with CKD and hypertension

Initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes.

This applies to all CKD patients with hypertension regardless of race or diabetes status.

Recommendation 8

Opinion for starting & adding drugs

.

Recommendation 9

The main objective of hypertension treatment is to attain and maintain goal BP.

If goal BP is not reached within a month of treatment: ◦ increase the dose of the initial drug OR ◦ Add a second drug from one of the classes in

recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB).

The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached.

Recommendation 9

If goal BP cannot be reached with 2 drugs: ◦ Add and titrate a third drug from the list provided.

Do not use an ACEI and an ARB together in the same patient.

If goal BP cannot be reached using the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP: antihypertensive drugs from other classes can be used.

Recommendation 9

For patients in whom goal BP cannot be attained using the above strategy OR

The management of complicated patients for whom additional clinical consultation is needed.

Referral to a hypertension specialist may be indicated

Recommendation 9

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JNC 7 vs JNC 8: Methodology

JNC 7 JNC 8 Nonsystematic

literature review by expert committee including a range of study designs

Recommendations based on consensus

Critical questions and review criteria defined by expert panel with input from methodology team

Initial systematic review by methodologists restricted to RCT evidence

Subsequent review of RCT evidence and recommendations by the panel according to a standardized protocol

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JNC 7 vs JNC 8: Definitions

JNC 7 JNC 8

Defined hypertension and prehypertension

Definitions of hypertension and prehypertension not addressed

But thresholds for pharmacologic treatment were defined

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JNC 7 vs JNC 8: Treatment Goals

JNC 7 JNC 8

Separate treatment goals defined for

“uncomplicated” hypertension

Subsets with various comorbid conditions (diabetes and CKD)

Similar treatment goals defined for all hypertensive populations

Except when evidence review supports different goals for a particular subpopulation

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JNC 7 vs JNC 8: Lifestyle recommendations

JNC 7 JNC 8

Recommended lifestyle modifications based on literature review and expert opinion

Lifestyle modifications recommended by endorsing the evidence based recommendations of the Lifestyle Work Group

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JNC 7 vs JNC 8: Drug therapyJNC 7

JNC 8 Recommended 5 classes to be

considered as initial therapy

Recommended thiazide-type diuretics as initial therapy for most patients without compelling indication for another class

Specified particular antihypertensive medication classes for patients with compelling indications, ie, diabetes, CKD, heart failure, myocardial infarction, stroke, and high CVD risk

Included a comprehensive table of oral antihypertensive drugs including names and usual dose ranges

Recommended selection among 4 specific medication classes

ACEI or ARB, CCB or diuretics

Doses based on RCT evidence

Recommended specific medication classes based on evidence review for racial, CKD, and diabetic subgroups

Panel created a table of drugs and doses used in the outcome trials

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JNC 7 vs JNC 8: Scope of topics

JNC 7 JNC 8

Addressed multiple issues blood pressure measurement

methodsPatient evaluation componentsSecondary hypertension Adherence to regimensResistant hypertension Hypertension in special

populations Based on literature review

and expert opinion

Addressed a limited number of questions, those judged by the panel to be of highest priority.

Evidence review of RCTs

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JNC 7 vs JNC 8: Review process prior to publication

JNC 7 JNC 8

Reviewed by the National High Blood Pressure Education ProgramCoordinating Committeea coalition of 39 major

professionalPublic and voluntary

organizations and 7 federal agencies

Reviewed by experts including those affiliated withProfessional Public organizationsFederal agencies

No official sponsorship by any organization should be inferred

Copyright © 2012 American Medical Association. All rights reserved. JAMA. 2013; doi:10.1001/jama.2013.284427

Figure Legend:

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´ Not a comprehensive guideline

´ Limited in scope ( focused evidence review to address the 3

specified questions).

´ Numerous comorbidities with HTN not addressed.

´ Adherence and medication costs.

´ RCTs with participants with normal BP were excluded.

´ Recommendations do not apply to those without HTN.

´ Treatment related adverse effects on health outcomes.

Limitations

Guidelines Offer clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies

Provides evidence-based recommendations for the management of high BP

Should meet the clinical needs of most patients.

However, these recommendations are not a substitute for clinical judgment, and decisions must carefully consider and incorporate the clinical characteristics of each individual.

Conclusion

THANK YOU